Reduction In Mean Time Research Articles

Combining Cyproheptadine Hydrochloride With Targeted Muscle Activation Training to Treat Upper Extremity Stroke: A Randomized, Placebo-Controlled Trial

ObjectiveTo examine a treatment for upper extremity impairment in stroke survivors that combines administration of cyproheptadine hydrochloride with repetitive practice focused on control of muscle activation patterns. DesignDouble-blind, randomized controlled trial. SettingsLaboratory within a free-standing rehabilitation hospital. ParticipantsA total of 94 stroke survivors with severe, chronic hand impairment were randomly assigned to 1 of 4 treatment groups. InterventionsParticipants received either a placebo or cyproheptadine hydrochloride in identical pill form. The daily dosage of cyproheptadine/placebo was gradually increased from 8 to 24 mg/d over 3 weeks and then maintained over the next 6 weeks while participants completed 18 therapy sessions. Therapy consisted of either (1) active practice of muscle activation patterns to play “serious” computer games or control a custom hand exoskeleton or (2) passive, cyclical finger stretching imposed by the exoskeleton. Main Outcome MeasuresHand control was evaluated with the primary outcome measure of time to complete the Graded Wolf Motor Function Test (GWMFT) and secondary outcome measures including finger strength and spasticity. ResultsAcross the 88 participants who completed the study, a repeated-measures analysis of variance revealed a significant effect of GroupxEvaluation interaction on GWMFT (F=1.996, P=.026). The 3 groups receiving cyproheptadine and/or actively practicing muscle activation pattern control exhibited significant reduction in mean time to complete the GWMFT tasks; roughly one-third of these participants experienced at least a 10% reduction in completion time. Gains were maintained at the 1-month follow-up evaluation. The group receiving placebo and passive stretching did not show improvement. No significant differences among groups were observed in terms of changes in strength or spasticity. ConclusionsDespite chronic, severe impairment, stroke survivors were able to complete the therapy focused on muscle activations and achieved statistically significant improvement in hand motor control. Cyproheptadine hydrochloride is a potential complementary treatment modality for stroke survivors with hand impairment.

Cytomegalovirus Matching in Deceased Donor Kidney Allocation: Results From a U.S. National Simulation Model.

Cytomegalovirus (CMV) infects >60% of adults and can pose an independent risk factor for allograft loss and mortality in solid organ transplant recipients. The purpose of this study is to evaluate the impact of a nationwide implementation of CMV seromatching (donor/recipient: D-/R- and D+/R+) in the U.S. deceased donor kidney allocation system (KAS). Adult candidates on the U.S. kidney-only transplant waiting list and deceased donor kidneys offered to the U.S. transplant centers were considered. A discrete-event simulation model, simulating the pre-COVID-19 period from January 1, 2015, to January 1, 2018, was used to compare the performances of currently employed KAS-250 policy (without CMV matching) to various simulated CMV matching policies parameterized by calculated panel reactive antibody exception threshold. Outcomes included CMV serodistribution, waiting time, access to transplantation among various groups, transplant rate, graft survival, kidney discard rate, and antigen-mismatch distribution, stratified by CMV serostatus. CMV matching policy with a calculated panel reactive antibody exception threshold of 50% (namely, the CMV">50%" policy) strikes a better balance between benefits and drawbacks of CMV matching. Compared with KAS-250, CMV">50%" reduced CMV high-risk (D+/R-) transplants (6.1% versus 18.1%) and increased CMV low-risk (D-/R-) transplants (27.2% versus 13.1%); increased transplant rate for CMV R- patients (11.54 versus 12.57) but decreased for R+ patients (10.68 versus 10.48), yielding an increase in aggregate (11.09 versus 10.94); and reduced mean time to transplantation (by 6 wk); and reduced kidney discard rate (25.7% versus 26.2%). Our findings underscore the feasibility and potential advantages of a nationwide CMV seromatching policy in kidney transplantation.

Enhancing Cloud Compliance: A Machine Learning Approach

The intersection of machine learning (ML) and cloud computing presents significant opportunities to enhance cloud compliance and security practices. This research paper explores the role of ML in improving cloud compliance, focusing on proactive threat detection, automated incident response, and adaptive security controls. The importance of ML-driven approaches lies in their ability to analyse large datasets, detect anomalies, and mitigate risks in dynamic cloud environments. Methods employed include case studies and experiments showcasing real-world applications of ML in cloud security, such as Google Cloud's Context-Aware Access and AWS GuardDuty for threat detection. Experimental findings demonstrate the effectiveness of ML models in reducing mean time to detect (MTTD) security incidents and improving incident response capabilities. Results highlight the transformative impact of ML technologies in bolstering cloud security effectiveness and resilience. ML-powered compliance monitoring systems, like Netflix's, have significantly improved compliance posture while reducing operational costs. Implications of this research include enhanced security governance, reduced compliance risks, and improved operational efficiencies within cloud infrastructures. Future directions entail exploring advanced ML techniques, addressing ethical considerations, and integrating ML-driven security frameworks into holistic cloud governance strategies.

Systematic review and meta-analysis on the effect of adjuvant gonadotropin-releasing hormone agonist (GnRH-a) on pregnancy outcomes in women with endometriosis following conservative surgery.

Endometriosis frequently results in pain and infertility. While conservative surgery offers some relief, it often falls short of ensuring satisfactory pregnancy outcomes. Adjuvant GnRH-a is administered post-surgery to mitigate recurrence; however, its impact on pregnancy outcomes remains debated. This study endeavors to assess the efficacy of adjuvant GnRH-a in enhancing pregnancy outcomes post-conservative surgery in endometriosis patients. Databases including PubMed, Embase, the Cochrane Library, Medline (Ovid), Web of Science, and Scopus were rigorously searched up to 02 August 2023, without linguistic constraints. Identified articles were screened using strict inclusion and exclusion criteria. Evaluated outcomes encompassed pregnancy rate, live birth rate, miscarriage rate, ectopic pregnancy rate, multiple pregnancy rate, mean postoperative pregnancy interval, recurrence rate, and adverse reaction rate. The Cochrane risk of bias tool and the Jadad score evaluated the included studies' quality. Subgroup and sensitivity analysis were implemented to analyze the pooled results. A meta-analysis model expressed results as standardized mean difference (SMD) and Risk ratio (RR). A total of 17 studies about 2485 patients were assimilated. Meta-analysis revealed that post-surgery, the GnRH-a cohort experienced a marginally elevated pregnancy rate (RR = 1.20, 95% CI = 1.02-1.41; P = 0.03) and a reduced mean time to conceive (RR = -1.17, 95% CI = -1.70- -0.64; P < 0.0001). Contrarily, other evaluated outcomes did not exhibit notable statistical differences. Incorporating adjuvant GnRH-a following conservative surgery may be deemed beneficial for women with endometriosis, especially before Assisted Reproductive Technology (ART). Nonetheless, owing to pronounced heterogeneity, subsequent research is warranted to substantiate these potential advantages conclusively. CRD42023448280.

A Knowledge Graph-based Learning Assistance Systems for Industrial Maintenance

Manufacturing industry is constantly evolving technologically. To ensure that the workforce comply with pace of changing requirements, Learning Assistance Systems (LAS) can provide competency-based support for daily tasks. LAS provide personalized support to blue and white collars through modular and contextualized workflows, information and learning materials. This paper presents a LAS designed and implemented for maintenance personnel in semiconductor manufacturing. The implemented LAS employs a novel statistical learning algorithm to determine the required competencies per task, interlinking them with information from knowledge bases and Manufacturing Execution Systems. This leads to a reduced mean time to repair of 18% in the illustrated use case.

Venous and lymphovenous lower limb wound outcomes in specialist UK wound and lymphoedema clinics.

To investigate the healing rates observed in patients who presented to wound and lymphoedema specialist clinics, located in the south eastern region of England, with venous/lymphovenous ulceration of the lower limb during the COVID-19 pandemic in 2020-2022 (30 months in all). A retrospective analysis of patient outcomes. 1041 patients were referred to the service, with a healing rate of 88.5% over 78 days. When comparing 2013-2019 healing rates/time to healing vs 2020-2022 there was a decrease of 1.5% in the rate of healing and a mean reduction in time to healing of 40 days. Despite the pandemic the service was able to maintain previous levels of outcomes and observed a decrease in the mean time to healing.

Improving Access and Timeliness of Early Palliative Care Specialist Assessment for Patients With Advanced Lung Cancer in a Rapid Assessment Clinic.

Background: Integrating palliative care in the management of patients with lung cancer improves quality of life, patient satisfaction, and overall survival. However, few patients receive timely palliative care consultation. The Lung Diagnostic Assessment Program (LDAP) in Southeastern Ontario is a multidisciplinary rapid assessment clinic that expedites the diagnosis and management of patients with suspected lung cancer. Objectives: We sought to increase the percentage of LDAP patients with stage IV lung cancer receiving palliative care consultation within three months of diagnosis. Design: We integrated a palliative care specialist in LDAP to facilitate in-person, same-visit consultation for patients with a new lung cancer diagnosis. Setting/Subjects: Five hundred fifty patients in a Canadian academic center (154 initial baseline, 104 COVID baseline, 292 post-palliative care integration). Measurements: Baseline data were established using retrospective chart review (February-June 2020 and December 2020-March 2021 due to COVID-19 pandemic). Data were collected prospectively to assess improvement (March-August 2021). Statistical Process Control charts assessed for special cause variation; chi-square tests assessed for differences between groups. Results: The percentage of patients with stage IV lung cancer seen by palliative care within three months increased from 21.8% (12/55) during early-COVID baseline to 49.2% (32/65) after palliative care integration (p < 0.006). Palliative care integration in LDAP reduced mean time from referral to consultation from 24.8 to 12.3 days, including same-day consultation for 15/32 (46.8%) patients with stage IV disease. Conclusions: Integrating palliative care specialists into LDAP improved the timeliness of palliative care assessment for patients with stage IV lung cancer.

From design to production: State-of-the-art web user interfaces to operate ALICE offline and online system

The ALICE Experiment at CERN’s Large Hadron Collider is currently undergoing a major upgrade during Long Shutdown; this entails a new Online-Offline computing system and a new set of reliable and performant graphical user interfaces. After deployment, the updated system is expected to read an estimated throughput of 27 Tb/s of raw data and index 800 of Gb/s reconstructed data. The newly developed graphical interfaces are to be used 24 hours a day, 365 days a year in the control room by the subsystem experts and on-call support staff. The interfaces are being built based on a common library developed in-house whose goal is to provide the core functionalities and building blocks, and on modern web technologies meant to ensure support for both Runs 3 and 4. This approach secures a consolidated user experience that is efficient, resilient, easy to maintain, and will bring live, straightforward control of the experiment and useful information to the collaboration. This, in turn, will help in our mission to increase the usage of the LHC beam, maximizing the recorded data and potentially leading to new discoveries. Furthermore, in order to guarantee the stability of the platforms, state-of-the-art technologies and practices were applied to build a continuous-integration and continuous-deployment environment to ensure high-quality code, faster releases, and reduced mean time to resolution. This paper provides an in-depth look at the newly developed web-based components including their features and architecture as well as the automated deployment workflow used for software quality assurance.

A competence-based planning methodology for optimizing human resource allocation in industrial maintenance

Maintenance planning in Industry 4.0 gains benefits from symbolic AI for knowledge representation learning from heterogeneous data. Traditionally simulation models are utilized that are not flexible to cope with dynamic changes and to react to ad-hoc events. This paper presents a novel competence-based maintenance planning (CBMP) methodology using a knowledge graph conjoined with linear programming and a genetic algorithm. Aligned with production planning goals, CMBP allows optimizing human resource planning through integrating competence factors in shift scheduling and task allocation. The use case study in semiconductor manufacturing has resulted in a reduced Mean Time To Repair of 18%.

Time and behavioral adjustments to lactation: Insights from a marine predator

AbstractThe energetic costs of lactation have been studied in many marine mammals, but little is known about the behavioral adjustments needed to cope with this event. By simultaneously measuring foraging behavior of lactating and nonlactating Antarctic fur seal females, we estimate the behavioral changes necessary to cope with the constraints of lactation and include the first comparative record of dive behavior between lactating and nonlactating female otariids. Nonlactating females exhibited highly variable foraging trip durations and spent long times onshore between trips. In contrast, lactating females exhibited consistently shorter trips and spent half the time hauled‐out compared to nonlactating females likely to maximize offspring provisioning. Lactating females show a reduced mean time per dive but greater percentage of time per trip spent diving compared to nonlactating animals. The reduction in time onshore and trip duration, together with modifications in dive performance suggests additional effort of lactating females to compensate for the constraints of rearing a pup, which has not been observed previously due to the lack of simultaneous comparison of lactating and nonlactating individuals. When possible, future studies of maternal investment should also include nonlactating individuals, since lactation may have a strong synergistic effect with other aspects shaping foraging behavior.

Meld Criteria in the Transplant Waiting List: Impact on Mortality Overall and by Diagnostic Groups

Abstract:Introduction: The modification of liver graft allocation for selection by severity criteria based on the Model for End-Stage Liver Disease (Meld) has not yet been properly analyzed in Brazil regarding the distribution of indications for transplant and mortality among enrolled patients. In a context of low organ donation and procurement, this assessment is relevant. Objective:To compare mortality on the liver transplant waiting list in Brazil before and after the adoption of Meld score as a criterion for allocation on the waiting list: overall, by diagnostic group, and by Meld range at enrollment. Methods:We retrospectively studied 899 patients (median age = 52.8 years, body mass index, BMI = 25.2 and Meld = 18) divided into the pre- (n = 320, 35.6%) and post-Meld (n = 579, 64.4%) periods and into groups: 1 (n = 480, 53.4%): ethanolic, cryptogenic and autoimmune cirrhosis; 2 (n = 80, 8.9%): biliary diseases; 3 (n = 93, 10.3%): metabolic and other diseases; and 4 (n = 246, 27.4%): post-viral B and C cirrhosis. Special scoring was assigned to 19.5% of patients, according to legislation criteria. The sample was also divided by Meld ranges at enrollment (&lt; 18; 18–24; and &gt; 24). Waitlist mortalities of the pre- and post-Meld groups were compared in the total sample, in each diagnostic group, and in each Meld range. Results:The incidence of referrals to transplantation was different in the pre- and post-Meld eras (p = 0.049), increasing in group 3 (from 8.1 to 11.6%) and decreasing in group 4 (from 32.5 to 24.5%). Of the enrollees, 32.9% died before transplantation. Mean Meld increased from 16 to 20 (p &lt; 0.001), and mean time between enrollment and outcome (transplant or death) decreased from 102 days to 58 (p = 0.028). Waiting list mortality dropped from 105.7% (patient-years) to 54.9% in the post-Meld group (p = 0.001). There was a reduction from 104.2% (patient-years) to 51.1% (p = 0.034) in group 1, and the proportion fell from 160.3% (patient-years) to 52% (p = 0.019) in group 2. On the other hand, there was no statistically significant variation in the groups 3 and 4. In Meld range 1 (&lt; 18), mortality ranged from 87.2% per patient-year to 24.1% per patient-year (p = 0.005). In Meld range 2 (18–24), it ranged from 109.8 to 72.4% per patient-year (p = 0.019). In the Meld &gt; 24 range, there was no significant change in waitlist mortality. Finally, survival at 1, 3 and 12 months after transplantation did not vary significantly between the pre-Meld and post-Meld era. Conclusion:Comparing the pre- and post-Meld groups, patients were enrolled when they were most severely ill, and there was a reduction in mean time on the list for the outcome and a decrease in waiting list mortality with no change in post-transplant survival. Diagnosis groups 1 and 2 have benefited. In addition, the decrease in waiting list mortality was observed among patients with Meld &lt; 24 at the time of enrollment. This reduction was not observed in the group of patients with Meld &gt; 24.

Accessibility of Level III trauma centers for underserved populations: A cross-sectional study.

By providing definitive care for many, and rapid assessment, resuscitation, stabilization, and transfer to Level I/II centers when needed, Level III trauma centers can augment capacity in high resource regions and extend the geographic reach to lower resource regions. We sought to (1) characterize populations served principally by Level III trauma centers, (2) estimate differences in time to care by trauma center level, and (3) update national estimates of trauma center access. In a cross-sectional study (United States, 2019), we estimated travel time from census block groups to the nearest Level I/II trauma center and nearest Level III trauma center. Block groups were categorized based on the level of care accessible within 60 minutes, then distributions of population characteristics and differences in time to care were estimated. An estimated 22.8% of the US population (N = 76,119,228) lacked access to any level of trauma center care within 60 minutes, and 8.8% (N = 29,422,523) were principally served by Level III centers. Black and American Indian/Alaska Native (AIAN) populations were disproportionately represented among those principally served by Level III centers (39.1% and 12.2%, respectively). White and AIAN populations were disproportionately represented among those without access to any trauma center care (26.2% and 40.8%, respectively). Time to Level III care was shorter than Level I/II for 27.9% of the population, with a mean reduction in time to care of 28.9 minutes (SD = 31.4). Level III trauma centers are a potential source of trauma care for underserved populations. While Black and AIAN disproportionately rely on Level III centers for care, most with access to Level III centers also have access to Level I/II centers. The proportion of the US population with timely access to trauma care has not improved since 2010. Prognostic/Epidemiological; Level IV.

New 3-Dimensional Volumetric Ultrasound Method for Accurate Quantification of Atherosclerotic Plaque Volume

BackgroundCarotid and femoral plaque burden is a recognized biomarker of cardiovascular disease risk. A new electronic-sweep 3-dimensional (3D)–matrix transducer method can improve the functionality and image quality of vascular ultrasound atherosclerosis imaging. ObjectivesThis study aimed to validate this method for plaque volume measurement in early and intermediate–advanced plaques in the carotid and femoral territories. MethodsPlaque volumes were measured ex vivo in pig carotid and femoral artery specimens by 3-dimensional vascular ultrasound (3DVUS) using a 3D-matrix (electronic-sweep) transducer and its associated 3D plaque quantification software, and were compared with gold-standard histology. To test the clinical feasibility and accuracy of the 3D-matrix transducer, an experiment was conducted in intermediate–high risk individuals with carotid and femoral atherosclerosis. The results were compared with those obtained using the previously validated mechanical-sweep 3D transducer and established 2-dimensional (2D)–based plaque quantification software. ResultsIn the ex vivo study, the authors assessed 19 atherosclerotic plaques (plaque volume, 0.76 µL-56.30 μL), finding strong agreement between measurements with the 3D-matrix transducer and the histological gold-standard (intraclass correlation coefficient [ICC]: 0.992; [95% CI: 0.978-0.997]). In the clinical analysis of 20 patients (mean age 74.6 ± 4.45 years; 40% men), the authors found 64 (36 carotid and 28 femoral) of 80 scanned territories with atherosclerosis (measured atherosclerotic volume, 10 μL-859 μL). There was strong agreement between measurements made from electronic-sweep and mechanical-sweep 3DVUS transducers (ICC: 0.997 [95% CI: 0.995-0.998]). Agreement was also high between plaque volumes estimated by the 2D and 3D plaque quantification software applications (ICC: 0.999 [95% CI: 0.998-0.999]). Analysis time was significantly shorter with the 3D plaque quantification software than with the 2D multislice approach with a mean time reduction of 46%. Conclusions3DVUS using new matrix transducer technology, together with improved 3D plaque quantification software, simplifies the accurate volume measurement of early (small) and intermediate–advanced plaques located in carotid and femoral arteries.

A Novel Endovascular Therapy Strategy for Acute Ischemic Stroke Due to Intracranial Atherosclerosis-Related Large Vessel Occlusion: Stent-Pass-Aspiration-resCuE-Micowire-Angioplasty (SPACEMAN) Technique.

BackgroundThere is no clear consensus on the optimal endovascular treatment strategy for patients with ischemic stroke caused by ICAS-related large vessel occlusion (LVO). SPACEMAN, a novel thrombectomy technique that entails passing an aspiration catheter over the stent retriever and then retaining the microwire for angioplasty, has not been described. The aim of this prospective study was to evaluate our initial application of SPACEMAN and compare this technique with the Solumbra technique.MethodsForty-four consecutive patients with acute ischemic stroke resulting from ICAS-related LVO were randomly divided into two groups: Solumbra group (n = 22) and SPACEMAN group (n = 22). Demographic and clinical data were prospectively collected. Modified Rankin Scale (mRS) score of ≤ 2 of anterior circulation and mRS score ≤ 3 of posterior circulation at 3 months post-discharge was regarded as good prognosis.ResultsThe SPACEMAN group showed reduced mean time from femoral access to recanalization compared with the Solumbra group (39.55 ± 10.63 min vs. 50.73 ± 9.89 min, P = 0.001). The overall recanalization rate in the entire cohort was 93.18% (41/44). At 3-month follow-up, the overall good prognosis rate was 47.73%; 13 patients (59.09%) in the SPACEMAN group and 8 (36.36%) in the Solumbra group showed good prognosis. One patient in the SPACEMAN group (4.55%) and two patients in the Solumbra group (9.09%) developed symptomatic intracranial hemorrhage. The overall mortality rate was 4.55% (2/44).ConclusionsThis study suggests that SPACEMAN exhibits a shorter operation revascularization time than the standard thrombectomy. Complications and prognosis were comparable between the two groups. The safety and efficacy of this novel technique need to be studied in larger patient series.

Evaluation of the Potential Impact of a Multiplex Rapid Diagnostic Panel in Critically Ill Patients With Hospital-Acquired Pneumonia.

BackgroundRapid diagnostic tools have emerged as valuable assets assisting clinicians in decision-making regarding patient management in the hospital setting. Our study sought to identify the potential impact of the BioFire® FilmArray® Pneumonia Panel (FP Panel) (BioFire Diagnostics, Salt Lake City, UT, USA) in patients with hospital-acquired pneumonia (HAP).MethodsRespiratory samples obtained by bronchoalveolar lavage (BAL) or tracheal aspiration (TA) from ICU patients with a diagnosis of HAP were tested by the FP panel in addition to routine bacterial cultures. In addition, the electronic health records of these patients were reviewed to determine what potential changes in antimicrobial therapy could have been implemented if the panel results were known to the treatment team in real-time. A cost analysis was also performed incorporating the cost of the pneumonia panel and the savings associated with the potential decrease of antibiotic use and avoidance of the rapid viral diagnostic panel. ResultsFifty-six patients met the study criteria. The FP panel results could have prompted a change in therapy in 36 (64.3%) patients, with an anticipated mean reduction in time to optimized therapy of approximately 51 hours. In addition, the panel identified three cases where antimicrobials should have been altered because patients were not receiving empiric therapy with activity against the causative pathogen and 34 opportunities for antibiotic de-escalation. The cost analysis calculated an additional cost of $10 per patient associated with using the FP panel. ConclusionsThe FP panel could have prompted a change in therapy in about two-thirds of patients studied. Its potential benefits include a more rapid time to optimized therapy, reduced exposure to and cost of broad-spectrum antimicrobials, and reduced cost of other rapid diagnostic tests.

Impact of orthogeriatric care management by orthopedic surgeons and physicians on in-hospital clinical outcomes: A difference-in-difference analysis.

The orthopedic surgery unit in our suburb serves a large elderly trauma population in addition to providing elective surgeries. As patients with hip fractures have become older and at higher risk of medical complications, our hospital has initiated integrated co-management of these patients by orthopedic surgeons and geriatricians from the point of hospital admission. The aim of this study was to evaluate the impact of the hospital policy change on hip fracture management and clinical outcome indicators. Using the difference-in-difference approach, in total, 288 consecutive patients with hip fractures treated during the 1year before and 2 years after transition to orthogeriatric care from a geriatric consultation model to integrated orthogeriatric care model were compared with 576 patients from other local hospitals. Despite a seasonal trend toward increased length of hospital stay in winter, the intervention significantly reduced the change in mean length of stay (mean difference [95% confidence interval], -12.9 days [-21.5 to -4.3]; P=0.007) and discharge to home tended to change less frequently (-12.6%; P=0.10). There was no significant reduction in mean time to surgery (-0.2 days; P=0.83), mortality (-0.8%; P=0.62), or complications (-1.0%; P=0.85). Changing our hip fracture service from a geriatric consultation model of care to an integrated orthogeriatric model significantly reduced length of hospital stay probably due to a lower chance of discharge to home. To our knowledge, this is the first study in Japan to compare two orthogeriatric care models considering the nationwide improvement in hip fracture management. Geriatr Gerontol Int 2022; 22: 138-144.

1032. Evaluation of a Multiplex Rapid Diagnostic Panel in Respiratory Specimens from Critically Ill Patients with Hospital-Acquired Pneumonia

BackgroundRapid diagnostic tests can be a valuable aide in clinical decision-making but often cost more than traditional cultures. Prior to its implementation at our institution, we sought to evaluate the potential clinical and financial impact of using the FilmArray® Pneumonia Panel® (FP panel) in patients with hospital-acquired pneumonia (HAP). MethodsThis was a retrospective, observational, comparative study conducted at an 885-bed academic medical center. Respiratory samples obtained by bronchoalveolar lavage or tracheal aspiration from adult intensive care unit (ICU) patients with a diagnosis of HAP from Nov 2019 – Feb 2020 were tested by the FP panel in addition to routine cultures. Medical records were reviewed to determine potential changes in antimicrobial therapy if FP panel results were known by the treatment team in real time. A cost analysis was also performed incorporating the cost of the FP panel and the savings associated with the potential avoidance of antibiotics and other rapid diagnostic tests normalized per patient. Results56 patients met study criteria. FP panel results could have prompted a change in therapy in 36 (64.3%) patients, with a mean reduction in time to optimized therapy of approximately 51 hours. The panel identified 3 cases where the causative pathogen was not treated by empiric therapy and 34 opportunities for antibiotic de-escalation, the most common being the discontinuation of empiric vancomycin. 36 patients had been tested with a Respiratory Virus Panel, which could have been avoided if the FP panel was used. The potential therapy impact based on specific ICU and respiratory culture results is summarized in Table 1. The cost analysis calculated an additional cost of &10 per patient associated with using the FP panel. Table 1. Potential Changes in Therapy Based on Patient Location and Culture Result ConclusionThe FP panel could have prompted a change in therapy in about two-thirds of patients studied. Its potential benefits include quicker time to optimized therapy, reduced exposure to and cost of broad-spectrum antimicrobials, and reduced cost of other rapid diagnostic tests.Disclosures James Johnson, PharmD, FLGT (Shareholder) Vera Luther, MD, Nothing to disclose

Integration of clinical pharmacists into a heart failure clinic within a safety-net hospital

BackgroundManagement of heart failure with reduced ejection fraction (HFrEF) requires timely initiation and up-titration of guideline-directed medical therapy (GDMT). In safety-net hospitals (SNHs), limited health care staff and resources make achievement of optimal medical therapy challenging. Recent studies have shown that medication titration performed by clinical pharmacists can improve outcomes in ambulatory management of HFrEF; however, the impact of these services within an SNH remains unknown. ObjectiveDetermine the impact of integrating clinical pharmacists into a heart failure (HF) clinic on initiation and titration of GDMT within an SNH. MethodsWe performed a single-center retrospective cohort study of patients with HFrEF treated in an ambulatory HF medication titration clinic within an SNH before and after clinical pharmacist integration. Primary outcomes included dose optimization rates of GDMT, time between clinic visits, and time to optimization of GDMT. Exploratory secondary outcomes were all-cause, HF, and cardiovascular acute care service utilization and all-cause, HF, and cardiovascular mortality before and after clinical pharmacist integration up to 6 months after initial clinic visit. ResultsA total of 153 patients with HFrEF were treated. Baseline characteristics in the pre- and postintervention groups were comparable. After clinical pharmacist integration, there was a statistically significant improvement in optimization of renin-angiotensin-aldosterone system inhibitor or hydralazine-nitrate equivalent (82% vs. 94%, P = 0.02). Dose optimization rates of beta-blockers (90% vs. 83%, P = 0.22) and mineralocorticoid receptor antagonists (57% vs. 57%, P > 0.99) were unchanged. There was a statistically significant reduction in mean time between clinic visits (26 vs. 14 days, P < 0.001) and in mean time to optimization of GDMT (88 vs. 45 days, P = 0.002). All-cause mortality was reduced (13% vs. 2%, P = 0.01). ConclusionIn SNHs, where limited health care staff and resources present as barriers to timely initiation and titration of GDMT, integration of clinical pharmacists into HF clinics can serve as a practical solution.

Multi-infusion with integrated multiple pressure sensing allows earlier detection of line occlusions

BackgroundOcclusions of intravenous (IV) tubing can prevent vital and time-critical medication or solutions from being delivered into the bloodstream of patients receiving IV therapy. At low flow rates (≤ 1 ml/h) the alarm delay (time to an alert to the user) can be up to 2 h using conventional pressure threshold algorithms. In order to reduce alarm delays we developed and evaluated the performance of two new real-time occlusion detection algorithms and one co-occlusion detector that determines the correlation in trends in pressure changes for multiple pumps.MethodsBench-tested experimental runs were recorded in triplicate at rates of 1, 2, 4, 8, 16, and 32 ml/h. Each run consisted of 10 min of non-occluded infusion followed by a period of occluded infusion of 10 min or until a conventional occlusion alarm at 400 mmHg occurred. The first algorithm based on binary logistic regression attempts to detect occlusions based on the pump’s administration rate Q(t) and pressure sensor readings P(t). The second algorithm continuously monitored whether the actual variation in the pressure exceeded a threshold of 2 standard deviations (SD) above the baseline pressure. When a pump detected an occlusion using the SD algorithm, a third algorithm correlated the pressures of multiple pumps to detect the presence of a shared occlusion. The algorithms were evaluated using 6 bench-tested baseline single-pump occlusion scenarios, 9 single-pump validation scenarios and 7 multi-pump co-occlusion scenarios (i.e. with flow rates of 1 + 1, 1 + 2, 1 + 4, 1 + 8, 1 + 16, and 1 + 32 ml/h respectively). Alarm delay was the primary performance measure.ResultsIn the baseline single-pump occlusion scenarios, the overall mean ± SD alarm delay of the regression and SD algorithms were 1.8 ± 0.8 min and 0.4 ± 0.2 min, respectively. Compared to the delay of the conventional alarm this corresponds to a mean time reduction of 76% (P = 0.003) and 95% (P = 0.001), respectively. In the validation scenarios the overall mean ± SD alarm delay of the regression and SD algorithms were respectively 1.8 ± 1.6 min and 0.3 ± 0.2 min, corresponding to a mean time reduction of 77% and 95%. In the multi-pump scenarios a correlation > 0.8 between multiple pump pressures after initial occlusion detection by the SD algorithm had a mean ± SD alarm delay of 0.4 ± 0.2 min. In 2 out of the 9 validation scenarios an occlusion was not detected by the regression algorithm before a conventional occlusion alarm occurred. Otherwise no occlusions were missed.ConclusionsIn single pumps, both the regression and SD algorithm considerably reduced alarm delay compared to conventional pressure limit-based detection. The SD algorithm appeared to be more robust than the regression algorithm. For multiple pumps the correlation algorithm reliably detected co-occlusions. The latter may be used to localize the segment of tubing in which the occlusion occurs.Trial registration Not applicable.

1363 Oesophago-Pleural Fistula After Pneumonectomy; A Systematic Review

Abstract Introduction Oesophago-pleural fistula (OPF) is an infrequent but highly complex complication of pneumonectomy with a mortality of up to 63%. There is a paucity of data on the optimal treatment strategy. Method Systematic review was conducted in line with PRISMA guidance concerning OPF following pneumonectomy. Demographic, operative and management data were analysed. Results 30 full manuscripts of the 76 abstracts were included in the analysis. Data was limited to case reports or small series. In total, information for 58 patients was included. Median age was 59 years, with a median follow up time was 18 months. Most authors adopted sepsis control with chest drainage and pleural lavage and the mean number of interventions was 1.6. Overall mortality was 31% (18/58). There was no significant difference between the time to presentation following left (29.2+/-39.28 months) and right pneumonectomy (66.24+/-110.62) (p = 0.2271) nor any significant difference between successful outcomes following intervention for OPF after left (11/14) compared to right pneumonectomy (31/41) (p = 0.8219) or 90-day mortality (p = 0.4571). However, 26% of patients had synchronous broncho-pleural fistula and 90-day mortality was significantly higher in these patients (6/15 vs 6/43. p = 0.0395). 25 patients who underwent additional pericardial, oesophageal or a nodal resection or intervention at the time of pneumonectomy had a significantly reduced mean time to presentation with OPF (21.49+/-60.15 vs. 84.99+/-114.31. p = 0.0148) and a higher 90-day mortality (8/25 vs 3/32. P = 0.0414). Conclusions Major heterogeneity of management hinders the introduction of standardised guidance of post-pnuemonectomy OPF. An MDT approach involving Oesophago-gastric and Cardio-Thoracic Surgery is vital.